OXYGEN THERAPYPresented By:

Brian Cayko, M.B.A., RRT, RCP

Objectives

Indications, Objectives, & Hazards of O2 Therapy

Medical Oxygen Oxygen Transport Oxygen Delivery COPD Hypoxic Drive

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Oxygen TherapyGeneral Goals/objectives

Correcting Hypoxemia By raising Alveolar & Blood levels of

Oxygen Easiest objective to attain & measure

Decreasing symptoms of Hypoxemia Supplemental O2 can help relieve

symptoms of hypoxiaLess dyspnea/WOB Improve mental function

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Oxygen TherapyGoals/objectives -cont’d

Minimizing CP workload CP system will compensate for Hypoxemia by:

Increasing ventilation to get more O2 in the lungs & to the Blood Increased WOB

Increasing Cardiac Output to get more oxygenated blood to tissues Hard on the heart, especially if diseased

Hypoxia causes Pulmonary vasoconstriction & Pulmonary Hypertension These cause an increased workload on the right side of

heart Over time the right heart will become more muscular &

then eventually fail (Cor Pulmonale)

Supplemental o2 can relieve hypoxemia & relieve pulmonary vasoconstriction & Hypertension, reducing right ventricular workload

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Oxygen Therapy

The difference between O2 % delivered v. Inspired

Patient Dependant!

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Oxygen Therapy Assessing the need for

oxygen therapy3 basic ways

Laboratory measures invasive or noninvasive

Clinical Problem or conditionCOPD, Surgery, etc.

Symptoms of hypoxemiaDyspnea, Neuro, HR, etc. 

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Oxygen Therapy

Assessing the need for oxygen therapy

Laboratory measures – invasive or noninvasive PO2 – partial pressure of oxygen

PAO2 – Partial Pressure of Oxygen in Alveoli PaO2 – Partial pressure of Oxygen in arterial blood

Hgb Saturation SpO2 – Pulse Oximetry of Oxyhemaglobin Saturax

Pulse Oximetry (SpO2) Non-invasive

Detects the saturation levels of Oxyhemaglobin How much of the Hgb that is capable of carrying

O2 actually is carrying O2 Technical Considerations / Problems

Inaccurate if Non-Pulsatile Must always palpate the patients pulse while

performing Pulse Oximetry Pulse & Pulse Ox’s heart rate monitor must correlate

Other Inaccuracy causes Poor perfusion/circulation Trauma CO Poisoning Some Nail Polish / Thickened & discolored nails

Medical Gases

All Medical Gases Are Drugs Require Prescription Quality of each gas is mandated by FDA

Medical O2 must be 99% Pure Anhydrous

Medical gas must be dry & free of oil/contaminants Cooled to dry Filter to clean

Composition of Room Air

Nitrogen 78.08% ~78% Oxygen 20.946% ~21% Trace gases ~1%

O2 Supply

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Oxygen TherapyAssessing the need for

Requires expert in-depth knowledge RT is always available for consultation

RT & Nurse will combine objective & subjective measures to confirm inadequate oxygenation

Objective Test results

Subjective Pt assessment Often recommend administration based solely on subjective measures

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Oxygen TherapyDesign & Performance

Low flow Devices Flow does not meet inspiratory

demand O2 is diluted with air on inspiration

Nasal Cannula transtracheal CatheterReservoir CannulasMustachePendant

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Nasal Cannula

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Oxygen TherapyLow Flow Devices

Nasal Cannula Adult

0-6 l/m >4L requires Humidity Can cause irritax, dryness, bleeding, etc. 24-44%

Pediatrics (> 1mo) Low flows if possible Always humidified

Neo 0-2 l/m Always humidified

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Oxygen TherapyLow Flow Devices

Reservoir Cannula

Frequent replacement No humidification Requires nasal exhalation

Nasal Stores ~20ml Aesthetically displeasing

Pendant Better aesthetically Extra weight can irritate

ears/face

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Oxygen TherapyLow Flow Devices

Reservoir masks Simple Mask Non-Rebreather

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Low Flow DevicesReservoir Masks

Simple Mask Gas gathers in mask Exhalation ports Air entrained thru ports & around

mask 5-10 L/M

<5 = CO2 rebreathing >10 = use more invasive mask

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Non-rebreather

Non-rebreather

• Utilizes one way valves• b/w reservoir & mask• on one exhalation port

• leak free will provide 100%• >~70% FiO2 is rare• Hard to provide leak

free system

• 1 L reservoir bag

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Oxygen TherapyLow Flow Devices

Performance Characteristics of Low Flow FiO2 varies with amount of air dilution, pt dependant

Must assess response to therapyObjective & Subjective

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Oxygen TherapyHigh Flow Devices

High FlowSupplies given FiO2 @ flows higher

than inspiratory demandUses Entrainment

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Oxygen TherapyHigh Flow Devices

Air Entrainment system What is Entrainment?

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Oxygen TherapyHigh Flow Devices - Entrainment AE Devices

AEM (Venti-Mask)

AE Nebulizer (Large Volume Nebulizer) cool/heated Aerosol

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Air Entrainment Mask

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Oxygen TherapyHigh Flow Devices – Entrainment

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Oxygen TherapyOther devices

Enclosures Tents Hoods Incubators

Others BVM Pulse Dose Cannula Concentrators

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Oxygen TherapySelecting Delivery Approach

Not one best method every time RT & their expert knowledge needs to be

available for: Consult Assessment/reassessment Alteration of therapy Discontinuation of therapy

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Oxygen TherapySelecting Delivery Approach Purpose (Objective)

Increase FiO2 to correct hypoxemia minimize symptoms of hypoxemia Minimize CP workload

Patient Cause & severity of hypoxemia Age Neuro status/orientation Airway in place/protected Regular rate & rhythm (minute Ventilation)

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Oxygen TherapySelecting Delivery Approach

Equipment Performance The more critical, the greater need for high

stable FiO2 Becomes more difficult the more critical due to

the patients varying respiratory pattern

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Oxygen TherapySelecting Delivery Approach Pt Categories

Emergency Highest FiO2 possible

NRB mask, BVM Critical Adult

>60% O2 NRB, Dual Entrainment systems

Stable adult, acute illness, mild hypoxemia Low to mod FiO2

Simple Mask, Nasal Cannula

COPD

Chronic Obstructive Pulmonary Disease Broad term used to describe non-reversible

generalized airway obstruction. Obstructive Airway Diseases

C OPD B ronchitis A sthma B ronchiectesis E mphysema

CO2 Retainer

All COPD patients are NOT CO2 RETAINERS!! Some may be, But each patient needs to be

assessed

CO2 Retainer In Obstructive airway diseases it is often for

the obstruction to trap air in the distal lungs CO2 is not eliminated from the body efficiently Over time, their body no longer reacts to High

levels of CO2 normally, i.e. increased ventilation

The result is CO2 retention

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Oxygen TherapyPrecautions & Hazards

Deprex of Ventilation 2 dominant stimulants to breathe in Blood

stream CO2 O2

Hypercarbic drive is blunted High PCO2 no longer stimulates pt to increase

Ventilax Hypoxic drive is the only stimulus left

suppression of Hypoxic Drive Due to applying to much O2

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Oxygen TherapySelecting Delivery Approach CO2 Retainer

Chronic disease adult (COPD w/ CO2 retainment) acute on chronic illness Ensure adequate oxygenation without depresseing

Ventilation SpO2 85-90% PaO2 50-60mmHg Use venti mask to control FiO2 precision Assess response to therapy!! If not maintainable on Cannula, use masks

Pt may remove mask frequently due to Discomfort Convenience Change in mental status

Encourage Cannula use b/w mask use if mask must come off for periods

Summary Call RT if in doubt, we are there to help you serve

the patient

Adult Delivery Nasal Cannula 1-6 L/m, 24-44%, humidify if >4 L/m,

Stable Simple Mask 5-10 L/m, 35-55%, <5 l/m causes CO2

retention, Distress Non-Rebreather Mask >10 L/m, ~60-100%, Dependant on

mask fit, Failure

COPD does NOT equal CO2 retainment